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Abstract

Introduction

Post-traumatic stress disorder is defined as a mental disorder that arises from the
experience of traumatic life events. Research has shown a high incidence of co-morbidity
between post-traumatic stress disorder and psychosis.

Case presentation

We report the case of a 32-year-old black African woman with a history of both post-traumatic
stress disorder and psychosis. Two years ago she presented to mental health services
with auditory and visual hallucinations, persecutory delusions, suicidal ideation,
recurring nightmares, hyper-arousal, and initial and middle insomnia. She was prescribed
trifluoperazine (5 mg/day) and began cognitive-behavioral therapy for psychosis. Her
psychotic symptoms gradually resolved over a period of three weeks; however, she continues
to experience ongoing symptoms of post-traumatic stress disorder. In our case report,
we review both the diagnostic and treatment issues regarding post-traumatic stress
disorder with psychotic symptoms.

Conclusions

There are many factors responsible for the symptoms that occur in response to a traumatic
event, including cognitive, affective and environmental factors. These factors may
predispose both to the development of post-traumatic stress disorder and/or psychotic
disorders. The independent diagnosis of post-traumatic stress disorder with psychotic
features remains an open issue. A psychological formulation is essential regarding
the appropriate treatment in a clinical setting.

Introduction

Post-traumatic stress disorder (PTSD) is defined as a mental disorder that arises
from the experience of traumatic life events. Documented symptoms include re-experiencing
the traumatic event, hyper-arousal and avoidance of stimuli associated with the trauma
[1]. None of the Diagnostic and Statistical Manual of Mental Disorders Text Revision
(DSM-IV-TR) diagnostic criteria refers to psychotic phenomena such as delusions or
hallucinations. Research has shown a high incidence of co-morbidity between PTSD and
psychosis; for example, psychosis with PTSD and vice versa [2]. The emergence of psychosis in PTSD raises important nosological questions about
the disorder. In our case report, we describe the case of a patient with PTSD who
later developed psychotic features. We will also discuss and review the nosological
and treatment implications of this co-morbidity. To the best of our knowledge, we
report the first case of PTSD with psychotic symptoms in a pregnant woman treated
with trifluoperazine.

Case presentation

We present the case of a 32-year-old black African, muslim woman with a history of
both PTSD and psychosis. She presented to mental health services for the first time
two years ago with a history of auditory and visual hallucinations, persecutory delusions,
suicidal ideation, recurring nightmares, hyper-arousal, and initial and middle insomnia.
She reported seeing blood on the walls, men in white following her and hearing voices
saying that some men were coming to get her. These symptoms were worse at night. She
became very distressed and troubled to the point of wanting to end her life.

Her background history suggested co-morbid PTSD. Twelve years ago, she saw her family
(parents, sisters and brother) being killed during the civil war in her birth country
in Africa. Her clinical PTSD symptoms, such as the recurring nightmares, hyper-arousal,
and initial and middle insomnia, began shortly afterwards. Eight years later, she
came to the UK as an asylum seeker. During her first few years in the UK, she had
no social support, was unable to speak English, experienced homelessness and was unsuccessful
in gaining asylum. Her auditory and visual hallucinations and persecutory delusions
started at this time. A few months before her first contact with mental health services,
her psychotic symptoms and PTSD features became more frequent and intense. With no
stable relationship she became pregnant and visited her general practitioner who referred
her to our first-episode psychosis unit.

Upon admission, she presented as well kempt yet she appeared distressed. She was withdrawn
and quiet and there was some delay in her responses to questions. She was tearful
and her mood was low but reactive. She described vivid and clear auditory and visual
hallucinations and persecutory delusions. Her medical psychiatric, personal, and family
histories were unremarkable. A physical examination, neurological examination and
brain magnetic resonance imaging (MRI) scan were normal. The results of our routine
blood investigations were in the normal range, and a pregnancy test was positive.
At our clinical interview, she clearly fulfilled the DSM-IV-TR criteria for PTSD and
psychotic disorder not otherwise specified (NOS).

Because of the intensity of her symptoms, her distress and suicidal ideation, our
mental health team recommended ongoing hospitalization. She was started on trifluoperazine
(5 mg/day) and cognitive-behavioral therapy for psychosis. She also started a prenatal
follow-up. She self-reported a partial improvement in her clinical picture and her
psychotic symptoms gradually resolved over a three-week period, although they occasionally
resurfaced when she was under stress or whenever her medication compliance lapsed.
She was discharged from hospital and is now living in temporary accommodation funded
by local services and waiting for her asylum re-application to be processed. She continues
to have ongoing PTSD symptoms associated with the initial tragic event as persistent
remembering of the stressor event with recurring and vivid memories, nightmares, hyper-arousal
and initial insomnia. She also avoids circumstances resembling the initial stressor
event, such as wars and violence.

Discussion

In our case report, we describe the case of a patient with PTSD with psychotic symptoms.
Her PTSD developed soon after a severe traumatic experience associated with a civil
war twelve years ago: she witnessed the murder of her nuclear family. Eight years
later she developed psychotic symptoms, which included auditory and visual hallucinations
and persecutory delusions. She finally presented two years ago to mental health services
in the context of major social stresses, an unwanted pregnancy, potential homelessness,
and a rejected asylum claim. Symptomatically, her psychosis responded well to treatment
but the PTSD features and stresses remain. Her follow-up is now directed towards dealing
with these issues, as well as preventing a relapse.

We reviewed the scientific literature regarding the diagnosis and treatment of PTSD
with psychotic symptoms. There are few case reports about the presence of PTSD with
psychotic features, mainly involving war veterans, but none using trifluoperazine
as a psychopharmacological treatment. In 2008, Floros et al. reported the case of a man with psychotic symptomatology after a traumatic event involving
the accidental mutilation of his fingers. His treatment plan included pharmacotherapy
and supportive psychotherapy with the establishment of a good doctor-patient relationship.
This biopsychosocial approach was made to integrate all aspects relating to his history
in a meaningful way [3].

In our case report, our patient had PTSD symptoms including experiencing recurrent
distressing images of the traumatic event, with a markedly diminished interest and
participation in significant activities and the avoidance of thoughts and conversations
associated with the trauma. She also had persistent symptoms of increased arousal,
with difficulty falling and staying asleep. PTSD with psychotic symptoms is associated
with a clinically significant impairment in social and occupational functioning, including
difficulties in getting a stable job and holding down relationships. According to
the DSM-IV-TR, PTSD is classified as an anxiety disorder but expressions of the disorder
may include obsessions, phobias, dissociations or depression [4]. Less characteristic and poorly studied, are the psychotic symptoms associated with
PTSD. Our patient presented with visual and auditory hallucinations and persecutory
delusions with content that mirrored her PTSD. In patients who do not have another
established severe mental illness, the presence of psychotic symptoms in PTSD might
be better captured as a dimension or sub-group of PTSD rather than psychosis NOS.

Mueser et al. have suggested that PTSD influences psychosis both directly, through the effects of
specific PTSD symptoms including avoidance, over-arousal and re-experiencing the trauma,
and indirectly, through the effects of common consequences of PTSD such as re-traumatization,
substance abuse and difficulties with interpersonal relationships [5]. Our patient had both; she frequently "relived" the traumatic event through intrusive
flashbacks and recurring dreams. Co-morbid psychosis has been described in approximately
20 to 40 percent of veterans with combat-related PTSD [6,7]. The prevalence of PTSD in patients with a severe mental illness is at least three
times higher (29 percent) than the general population [5]. In PTSD, the psychotic symptoms may be more pervasive or frequent than psychotic-like
symptoms that occur during dissociative episodes or flashbacks [8]. PTSD with psychotic symptoms has also been reported in non-combat related cases
of patients with PTSD but not schizophrenia-spectrum or bipolar disorders.

From a psychological point of view, there is a relationship between the individual's
pre-existing cognitive schemas and thought patterns emerging after the traumatic event.
A maladaptative cognitive processing style culminates in feelings of shame, guilt
and worthlessness, which emerge during trauma acting as positive feedback to enhance
symptom severity and keep the individual in a constant state of psychotic turmoil.
It is possible that under certain individual-specific conditions, the defence and
coping mechanisms break down at a level of psychotic manifestations in the form of
delusions and hallucinations. It has been hypothesized that trauma may produce a psychological
vulnerability leading to the development of psychotic experiences. In our patient,
factors such as an unwanted pregnancy, potential homelessness and a rejected asylum
claim may have contributed to and triggered the emergence of psychotic features in
a preceding PTSD. Some authors underline the importance of both disorders being characterized
by intrusions. In PTSD, the interpretation of intrusive symptoms such as flashbacks
is seen as central to the maintenance of the disorder. In psychosis, hallucinations
and delusional beliefs are interpretations of intrusions [9].

Unlike our case report, where there was clear evidence of a life-threatening trauma
before psychotic symptoms, some authors identify psychosis itself as the source of
trauma for patients with both conditions. There is some evidence suggesting that psychosis,
hospitalization, or both may be sufficiently severe to precipitate PTSD and that psychological
distress related to a psychotic episode may predict an evolution to PTSD [10].

Our patient was an immigrant from a black ethnic minority group. First- and second-generation
black ethnic minority migrants are at a particularly high risk of psychosis in London.
The explanation for these findings is uncertain, but social adversity, racial discrimination,
family dysfunction, unemployment, poor housing conditions and urbanicity have been
proposed as contributing factors [11-13]. It is possible that similar stresses contributed to the heightened risk of psychosis
in our patient.

Some authors argue for a new condition called PTSD with psychotic symptoms, claiming
that it should be included in the psychiatric classification systems to account for
the high percentage of psychotic symptoms in patients with PTSD [14]. Our patient could fit into this category.

Establishing a correct diagnosis is imperative in developing an appropriate treatment
strategy, particularly when the presence of psychotic symptoms necessitates the use
of anti-psychotic medication. In addition to the demonstrated efficacy of selective
serotonin re-uptake inhibitors (SSRIs), a range of other drugs, including second-generation
anti-psychotics, have recently been investigated for the treatment of PTSD. The currently
available evidence suggests that first-line pharmacotherapy is SSRIs and possibly
the serotonin norepinephrine re-uptake inhibitor venlafaxine extended release [15]. Response rates are limited: approximately 60 percent of patients treated with SSRIs
are reached [16]. Psychotic symptoms are associated with more severe symptomatology and their presence
is also known to decrease the efficacy of conventional treatment [17], further indicating a possible role for an anti-psychotic treatment. We found a paucity
of randomized, double-blind, placebo-controlled clinical trials (RCT) of anti-psychotics
for the treatment of PTSD. However case reports, small RCTs and open-label studies
have demonstrated the beneficial effect of this pharmacotherapy (add-on and monotherapy)
for the treatment of PTSD patients with and without psychotic symptoms. Published
case reports demonstrate the efficacy of clozapine [8] or amisulpride [3] in the treatment of both PTSD and psychotic symptoms. Fluphenazine, olanzapine, risperidone
and quetiapine are anti-psychotics with demonstrated efficacy in open clinical trials
as a monotherapy in PTSD with psychotic features [18-20].

Hamner described the case of a Vietnam veteran with a history of PTSD symptoms and
psychotic symptoms including auditory hallucinations, visual hallucinations, thought
disorder and paranoid ideation. He had a history of substance abuse (alcohol and cocaine)
but had been in remission for one year prior to his evaluation. He was treated unsuccessfully
with typical neuroleptics, electroconvulsive therapy, benzodiazepines and lithium.
Clozapine was initiated and titrated to 600 mg/day leading to an improvement of his
PTSD and psychotic symptoms [8].

However, to date, none of these agents has received registration status for use in
PTSD in the USA or in Europe [21]. In the absence of guidelines relating to the condition of PTSD with psychosis, our
patient's psychosis responded well to the standard anti-psychotic treatment but her
co-morbid PTSD features remain. Given her complicated presentation, her recovery will
require a multi-faceted approach with an emphasis on addressing her pre-existing PTSD.
She did not develop any extra-pyramidal symptoms associated with the use of a typical
anti-psychotic, however, Chan et al. report the cases of three patients with PTSD with psychotic features who developed
severe extra-pyramidal side effects, namely akathisia, leading to the withdrawal of
the anti-psychotic medication [22].

Several psychotherapeutic interventions have been studied in PTSD and psychotic illnesses,
with a growing literature suggesting that they are both feasible and effective. Waldfogel
et al. report the case of a non-combat veteran with PTSD with psychotic symptoms who was
not successfully treated with anti-psychotics and for whom exposure therapy was successful
in treating PTSD and psychosis [23]. Mueser et al. published a randomized controlled trial of the cognitive-behavioral treatment (CBT)
of PTSD in severe mental illness, which includes breathing retraining, education about
PTSD and cognitive restructuring. Results indicated that patients included in a 12-
to 16-session CBT program showed a greater improvement of their PTSD symptoms, other
symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD,
and case manager working alliance compared with treatment as usual, where patients
continued to receive the usual treatments they had been undertaking in local mental
health centers [24]. Frueh et al. report an open trial in adults with PTSD and either schizophrenia or schizoaffective
disorder who were treated via an 11-week cognitive-behavioral intervention. The trial
involved 22 group and individual sessions for PTSD consisting of anxiety management
therapy, psycho-education, social skills training and exposure therapy. Participants
showed a significant improvement of their PTSD symptoms and high treatment satisfaction
[25]. Besides the psychopharmacological therapy, our patient could benefit from one of
these psychotherapeutic programs targeting PTSD symptoms.

As in the case report published by Waldfogel et al., patients presenting with PTSD with psychotic features who do not have a well established
severe mental illness might also respond to conventional psychotherapeutic treatments
with a demonstrated efficacy for the treatment of PTSD in the general population [23]. Due to the paucity of published systematic studies, this is a field for future research.

Because our patient has no friends or family in the UK, our diagnosis was based only
on self-reported information; a less rigorous approach than those using other sources
of information to corroborate a patient's account. A structured clinical interview
and the use of specific measure instruments could also help in rating symptoms and
promoting an improvement in clinical daily routine.

Conclusions

There are many factors responsible for the symptoms that occur in response to a traumatic
event, including cognitive, behavioral, physiological, affective and environmental
factors. These factors may predispose to the development of PTSD and/or psychotic
disorders. The independent diagnosis of PTSD with psychotic features remains an open
issue. Evidence seems to demonstrate that the two disorders - PTSD and psychosis -
may both emerge from a traumatic experience, or that PTSD itself may increase the
risk of subsequent psychotic illness. A psychological formulation addressing the potential
causes of PTSD and psychosis that could be treated with specific interventions (such
as CBT) is essential.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

RC designed the study, reviewed the existing literature and drafted the manuscript.
PP carried out the follow up on the patient, took part in the scientific discussion
and helped to draft the manuscript. All authors read and approved the final manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case
report and any accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.